Mother's Name *

First Name

Last Name

Phone *

(###)

###

####

Estimated Due Date *

MM

DD

YYYY

Partner's Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthing Location Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you taken a tour of your birthing location?

Yes

No

I'm planning too

Cancellation Policy

There is a 48-hour cancellation policy. Cancellations made at least 48 hours in advance will receive a refund, minus a $15 processing fee.

I have read and agree to the terms above.

Waiver and Release of Liability Agreement

I hereby confirm and understand that I have requested to receive information related to Childbirth Education including but not limited to stages of labor, common interventions, exercises, hands-on techniques, positions, and other informational content which will involve the exchange of information regarding childbirth. I fully understand that it is my responsibility to use all of the information provided by Samantha Hoppes/Mindful Mama South Bay to reach my own conclusions about childbirth, including the medical decisions I will make for my baby and me. I hereby assume all of the risks of childbirth and of participating in this course and I understand that the information provided here is for education purposes only. It is not meant to substitute information provided by a medical care provider. Samantha Hoppes/Mindful Mama South Bay shall not be liable for any outcome of my prenatal care, birth, or postpartum. I assume all responsibility for my own health care decisions and any and all risk that may arise from my decision-making. I certify that I am physically capable of using the positions suggested by Samantha Hoppes/Mindful Mama South Bay in this course, and that I have not been advised to not participate in position changes and comfort techniques by a medical professional. I waive, release, and discharge from any and all liability, including but not limited to liability arising from the negligence or fault of the entities or persons release, for my death, disability, personal injury, property damage, or actions of any kind which may hereafter occur to me from Samantha Hoppes/Mindful Mama South Bay, and their members, directors, officers, contractors, volunteers, representatives, and agents. To the fullest extent permitted by law, I hereby indemnify, hold harmless, and promise not to sue the Release Parties mentioned in this paragraph from any and all liabilities or claims made a result of my participation in this course and from my own birth, whether caused by the negligence of the Release Parties or otherwise. I further agree to indemnify, defend and hold the Released Parties harmless to the fullest extent permitted by law from and against any third-party claims, loss, liability, damages, costs and expenses (including reasonable attorney’s fees) relating to or arising out of my participation in this course. I further acknowledge and understand that all of the information, techniques, exercise, regimens and suggestions provided during the course is only for general informational purposes; it does not constitute medical advice or medical treatment. I certify that I have read this document, and I fully understand its content. I am aware that this is a release of liability and enforceable contract and by purchasing and participating in this course I am accepting the terms and conditions.

I have read and agree to the terms above.